Medicaid coverage for ICP, Hospice, HCBS (SMMC LTC, iBudget, and Cystic Fibrosis) and PACE programs may have a patient responsibility based on the individual’s gross monthly income and their placement. The amount of the patient responsibility is determined by subtracting the personal needs allowance (PNA) and other allowable deductions from the individual’s gross monthly income. See DCF Policy Passage 2640.0118 Personal Needs Allowance for more details. The other allowances and deductions that may apply are spousal and/or family allowance, court ordered child support only, and uncovered medical expense deductions (UMEDS). The amount of the PNA is determined by program and the placement type where the individual resides; at home, in a nursing facility, or an ALF.
For the Statewide Medicaid Managed-Long Term Care program and the Program for All-Inclusive Care for the Elderly (PACE), the personal needs allowance is as follows: (1) residing in a nursing facility is $105.00; (2) residing in an ALF is ALF basic monthly Room and Board rate plus 20% of the Federal Poverty Level (PVL); and (3) residing in the community (at home) is 300% of the Federal Benefit Rate.
The applicant applies and is approved for ICP and reports a nursing home expenses totaling $8,000.00 (UMED) prior to the month of approval.
$1,300.00 monthly income – $105 Personal Needs Allowance (PNA) = $1,195.00
$1,195.00 * 6 months = $7,170.00
$8,000.00 nursing home bill – $7,170.00 = $830.00 remaining balance of bill
$8,000.00/6 = $1,333.33 = $0.00 patient responsibility for each month
Since the nursing home bill exceeds the monthly income, use the remaining balance from the bill when determining the patient responsibility for the next six months. At the six-month review, the remaining balance of the nursing home bill of $830.00 is used as an uncovered Medical Expense Deduction (UMED).